Healing from the Bitter Pill of Incivility

Not long ago, I was facilitating a workshop on fostering civility in nursing education when a faculty member approached me during the break. The soft-spoken professor related her thoughts in a quiet voice, her eyes reflecting a certain sadness as she spoke. She said, “Please think about us—the clinical faculty, I mean—when you are speaking about incivility in nursing education. I am a member of the clinical faculty, and I can tell you, unequivocally, that we are a marginalized group. We are not considered part of the ‘real faculty’ and are often referred to as ‘minions and underlings.’ We are frequently told that we have no clout nor can we provide input into the theoretical courses or exams.” I asked the faculty member how she responded to these incivilities. She said, “I just take it—it’s like swallowing a very bitter pill.”

What I call the in-group and the out-group of nursing faculty teams—and I use the word “team” lightly—is further illustrated by a story described in a study I recently conducted to examine faculty-to-faculty incivility and ways to effectively address the problem. Approximately 13% of the respondents reported experiencing racial, ethnic, sexual, gender, or religious slurs within the past 12 months. One respondent wrote, “During a faculty workshop, faculty members were asked to work in small groups. One group contained four minority faculty members. A non-minority faculty member asked, ‘Do I have to paint my face black to be in this group?’”

Another faculty member related the incivility of perceived ageism that exists in her nursing program. She explained that when she met with her dean to seek advice about returning to graduate school to complete her doctoral degree, the dean laughed and said, “Are you kidding, at your age? You can’t be serious. By the time you finish your degree, you’ll be ready to retire. We prefer to invest in younger faculty.” Other forms of discrimination are also apparent: a student recently commented on faculty bias in the classroom, saying, “Students are often subjected to religious, racial, and anti-gay/lesbian content. We [students] feel vulnerable and do not know how faculty and administrators will react if they complain. It’s appalling and inexcusable.”

Regardless of their origin, uncivil encounters are an affront to human dignity and an assault on a person’s intrinsic sense of self-worth. The effects can be devastating and longlasting. Incivility may come from myriad sources; it is complex, disordered, and multidimensional. Taking time to engage, communicate, and listen with intention has a profound effect on preventing and healing the effects of incivility.

I often refer to incivility as a dance, an expression of feeling and social interaction that gets articulated through a variety of movements, gestures, and actions.1 Each observer and participant interprets the dance within the context of his or her personal experiences, through the lens of his or her own world-view. Because of this individual perception and interpretation, it becomes essential to actively listen, consider the intent of the action, and engage in meaningful and solutionbased conversation.

More than two decades ago, Ernest Boyer asserted that institutions of higher education play a vital role in helping students develop a sense of civic and social responsibility, and become productive citizens of the academy and the community.2 The promotion of civility and good citizenry is especially important in nursing and other health-related disciplines where the risk assumed by not addressing uncivil behavior reaches well beyond the college campus and can negatively impact patient safety, recruitment and retention, and commitment to the nursing profession. Because nursing programs are places where students and faculty provide direct care to patients through clinical experiences, uncivil and disruptive acts must be addressed so that such behaviors do not spiral into aggression and jeopardize the learning and practice environment.

While promoting civility is one of the primary functions of higher education, in some respects the system is failing. This failure may be related to a lack of understanding about the topic in general, and ways to prevent and address incivility in particular. I define incivility as rude or disruptive behaviors that often result in psychological or physiological distress for people involved, and if left unaddressed, may progress into threatening situations.3 Exposure to uncivil behaviors can result in physical symptoms such as headaches, interrupted sleep, and intestinal problems and can cause psychological conditions like stress, anxiety, irritability, and depressive symptoms. Thus, it is important to foster civility—an authentic respect for others requiring time, presence, a willingness to engage in genuine discourse, and an intention to seek common ground.4

Similarly, it is important to raise awareness about the importance of fostering a civil and healthy academic work environment. According to researchers, a healthy academic environment consists of a number of factors, including a clear mission with shared values and norms; high morale, job satisfaction, and an esprit de corps; competitive salaries and benefits; reasonable workloads; positive employee recruitment and retention; policies to eliminate incivility; respectful communication, teamwork, and shared decision making; organizational support and collegial relationships; and competent, honest leaders who collaborate with faculty to share decision making.5,6,7

Awareness may be raised by describing specific rationale for establishing and sustaining healthy academic work environments. First, the costs of incivility are vast. Uncivil behavior adds to employees’ stress level, erodes self-esteem, damages relationships, and threatens workplace safety and quality of life.8 Incivility also lowers morale, causes illness, and leaves workers feeling stressed, vulnerable, and devalued. The human and financial costs of these behaviors may be disastrous.9 Second, the recent Institute of Medicine Report10 includes several recommendations that call for nurses and other health care workers, such as physicians, to collaborate to advance the nation’s health. To fulfill these recommendations, we must establish civil and respectful relationships and interactions. Third, the American Nurses Association Code of Ethics for Nurses with Interpretive Statements Provision 1.5 promotes a civil, healthy work environment by requiring nurses to treat colleagues, students, and patients with dignity and respect, and states that any form of harassment, disrespect, or threatening action will not be tolerated.11 Similarly, the American Nurses Association Standards of Practice reinforce the need for objective standards such as collaboration, ethical conduct, and communication for nurses to be accountable for their actions, their patients, and their peers.12 These rationales and fostering a healthy academic work environment are difficult, if not impossible to achieve in the absence of skilled, ethical leadership. Successful change requires both formal and informal leadership—leaders who hold formal positions as well as individuals without a formal title or authority, but who have significant influence with members throughout the organization.

Once awareness is raised and leaders agree that changes are needed to foster a civil workplace, it is highly desirable to use empirical measures to determine levels, types, and frequency of civil and uncivil factors, and to reveal strategies for fostering a healthy workplace. Some examples of empirical measures include the Organizational Civility Scale (OCS)13 and the Culture/Climate Assessment Scale (CCAS).14 Other data sources are also helpful, such as formal and informal reports, evaluations, satisfaction surveys, performance evaluation information, regulatory reports, and information from focus groups and open forums. Once a comprehensive organizational assessment has been conducted, strategies can be implemented to improve areas of concern and to reinforce efforts already in place to enhance areas of strength and excellence.

Specific strategies include aligning the organizational mission and values with a focus on civility and respect. Successful organizations intentionally focus their vision for the future so that employees are able to meet organizational objectives as well as achieve personal satisfaction in their work. Organizational values undergird the formulation and implementation of norms of decorum. Without functional norms, desired behavior is ill defined and thus, members of the campus community are left to “make things up as they go along.”

Healthy academic work environments do not occur by accident—creating them requires intentional and purposeful focus. Unfortunately, many faculty, students, and administrators are unaware of how their behaviors affect others, and many are ill equipped to deal with incivility. Thus, strategies to prevent and address incivility must be taught, practiced, reinforced, and supported. We must make civility a priority. Faculty and staff meetings are excellent venues to raise awareness, discuss acceptable and unacceptable behaviors, establish norms of behavior, and practice and role-play civil interactions. When faculty and staff collectively co-create norms for behavior, they are more likely to approve of and conform to these behaviors. Once the norms are agreed upon, they become the standard for faculty and staff interactions. It is also important to establish, implement, and widely disseminate confidential, non-punitive policies and procedures for addressing incivility. This includes enforcing sanctions if indicated, and perhaps more importantly, to reward civility and collegiality. Although positive motivators are preferred, the consequences for violating the agreed-upon norms must be clearly stated and enforced. Ignoring or failing to address the uncivil behavior damages the organization as much, if not more, than the incivility itself.

Acting civilly and respectfully isn’t always easy, especially in a high-stress learning environment where constant change is the norm, and where faculty and students experience complex and demanding workloads. Yet, we must make civility a priority for our students, colleagues, practice partners, and ourselves. Incivility takes a tremendous toll on everyone throughout the campus and practice community. In a fast-paced work environment, patience is often in short supply, yet it remains a virtue we should value and uphold. Each individual must set a positive example to lead the transformation for cultivating civility in nursing education.


  1. C.M. Clark, “The Dance of Incivility in Nursing Education as Described by Nursing Faculty and Students,” Advances in Nursing Science (2008), 31(4), E37–E54.
  2. E. Boyer, Campus Life: In Search of Community. Princeton: The Carnegie Foundation for the Advancement of Teaching, 2009.
  3. C.M. Clark, “Faculty Field Guide for Promoting Student Civility,” Nurse Educator, 34(5),194–197.
  4. C.M. Clark and J. Carnosso, “Civility: A Concept Analysis,” Journal of Theory Construction and Testing, 12(1), 11–15.
  5. C.M. Clark (in progress), “Pathway for Fostering Organizational Civility.”
  6. M. Brady, “Healthy Nursing Academic Work Environments,” OJIN: The Online Journal of Issues in Nursing (2010), 15(1),Manuscript 6.
  7. National League for Nursing. “Healthful work environments for nursing faculty.” Retrieved February 26, 2012, www.nln.org/newsletter/healthfulworkenv.pdf.
  8. P.M. Forni, The Civility Solution, New York, NY: St. Martin’s Press, 2008.
  9. C. Pearson and C. Porath, The Cost of Bad Behavior: How Incivility is Damaging Your Business and What to do About it. New York, NY: Penguin Group, Inc, 2009.
  10. Institute of Medicine Report (2010). “The future of nursing: Leading change, advancing health,” Robert Wood Johnson Foundation Publisher.
  11. American Nurses Association. (2001). Code of Ethics for Nurses With Interpretive Statements. Washington, D.C.: American Nurses Association.
  12. American Nurses Association. (2010). Nursing Scope and Standards of Practice. (2nd ed). Silver Spring, MD: American Nurses Association.
  13. C.M. Clark and R.E. Landrum, “Organizational Civility Scale.” Retrieved February 26, 2012, http://hs.boisestate.edu/civilitymatters/
  14. C.M. Clark, M. Belcheir, P. Strohfus, and P.J. Springer, “Development and Description of the Culture and Climate Assessment Scale, Journal of Nursing Education (2012), 51(2), 75-80.

Nursing School Diversity Directors: What Do They Do and What Difference Are They Making?

Diversity directors appear to be a small but dedicated niche among nursing schools that are making an effort to better include and serve people of varying racial, ethnic and cultural backgrounds. While campus-wide diversity and multicultural affairs offices are fairly common at major U.S. universities, it’s rarer for nursing schools—or other individual colleges and professional schools, for that matter—to have a diversity department of their own.

“There have been pockets, but it hasn’t been done consistently, and there hasn’t been a big vision ,” says Mary Lou de Leon Siantz, PhD, RN, FAAN, assistant dean for diversity and cultural affairs at the University of Pennsylvania School of Nursing in Philadelphia.

There’s at least one reason, however, why the idea of establishing an office dedicated to enhancing the recruitment, retention and teaching of a diverse population may soon catch on at more nursing schools. “Now more than ever, because of the changing demographics of the United States, [a greater focus on multiculturalism in nursing education and practice] is very badly needed,” notes Siantz, who is a past president of the National Association of Hispanic Nurses.

By having their own formalized diversity departments and appointing diversity directors, nursing schools are in a position not only to create a more inclusive profession but also to prepare future nurses to meet the health care needs of an increasingly multicultural patient population. But what exactly do diversity directors do? And is this an emerging career opportunity that more minority nurses should consider pursuing?

The Mission and the Vision

One of the first tasks that Lillian Stokes, PhD, RN, FAAN, took on when she took the helm of the Office of Diversity and Enrichment at Indiana University School of Nursing in Indianapolis was to help fashion a diversity mission statement. Today, she sees that message displayed on a bronze plaque each time she walks through the front entrance of the school.

“Our overall vision is to try to promote an environment that values respect and reflects a global view of diversity,” says Stokes, who is also an associate professor at Indiana and the national president of Chi Eta Phi, a sorority for minority nurses.


Clarifying the vision of a diversity department usually starts with determining what diversity means. “We define diversity here as ‘holding multiple perspectives without judgment,’” says G. Rumay Alexander, EdD, RN, director of the Office of Multicultural Affairs and associate clinical professor at the University of North Carolina-Chapel Hill School of Nursing.

Nursing school diversity directors say they want to expand the definition of diversity beyond the familiar parameters of race, ethnicity and gender. “One of the things I always talk to our first-year students about is the need to think about diversity in broader terms, not just [in terms of] ethnicity,” says Jana Lauderdale, PhD, RN, assistant dean for cultural diversity at Vanderbilt University School of Nursing in Nashville. “That’s something I kind of preach all the way through the program.”

The term can apply to any subculture or underrepresented group, she explains–for example, homeless persons, people with disabilities or people with chronic illnesses.
In Alexander’s view, achieving diversity means more than simply admitting more students from diverse backgrounds. These students need to find a supportive environment that will help them succeed.

“If you’re inviting people into an environment that for whatever reasons does not feel welcoming to them, or treats some [members] of its community in an inequitable way, then you may be bringing in many people through the door, and your numbers may be going up in terms of admissions,” she says. “But if these students are not successful in matriculating through the program and graduating, then it’s kind of like coming in the front door of a house and going out the back door.”

At Penn, Siantz says a key element of the school’s vision is that the commitment to diversity must be top-down. “That means that at the top there is recognition of the need to diversify the administration and the faculty, as well as the student body, to better promote the mission of the school,” she explains. “Diversity is the number one strategic goal of the School of Nursing. Globalization is the second.”

The Scope of the Job

A common thread in the job descriptions of nursing school diversity directors is a major focus on assisting students. Some are also involved in faculty programs and curriculum development.

At Indiana University School of Nursing, Stokes’ Office of Diversity and Enrichment is part of the Center for Academic Affairs. The enrichment part of her job title is broad in scope.

“This position calls for working with all students, not just minority students or underrepresented students,” she says. “Although the faculty and my office are committed to supporting underrepresented students as much as possible, I probably see just as many or more majority students.”

Diversity-related programs at Indiana’s nursing school include “empowerment sessions” to aid students with test taking, stress management, time management, organization and other skills; peer-led tutorial reviews of specific classroom subjects; a Diversity Forum series featuring presentations by faculty members and local and national leaders; and workshops for faculty on teaching students from diverse cultures.
Recruitment of minority and international students is another aspect of Stokes’ job, although she says it’s not her primary role. “We have a marketing and recruitment person [who is in charge of that],” she explains. “I work very closely with that office, and also with our graduate offices.”

Stokes and some of the senior nurse researchers on the faculty have established a program called Connections that targets students who might be good candidates for the PhD program in nursing. “We meet with students—it may be one student or ten—who express an interest or who I see have potential,” she says. “We take them through the admissions process [and] get them to start thinking about their research area, so we can think about a faculty member who might work with them.”

Two students–one African American and one Nigerian–who participated in Connections have since begun their doctoral studies in the School of Nursing. “They are doing very well,” Stokes reports.

She is also a founding member of the nursing school’s Minority Advisory Council, now called the Diversity and Enrichment Council. The group includes faculty, students, staff and community partners, such as practicing nurses, politicians and leaders of local organizations.

Lauderdale, who is president-elect of the Transcultural Nursing Society, says the range of her job at Vanderbilt “seems to be a moving target. Almost every day, there seems to be another layer added to it, which tells you something about the scope of the need for a position of this type.”

Lauderdale’s initial focus was on ensuring a “cultural diversity content thread” throughout the curriculum, “so that by the time students graduate, they feel comfortable working with patients from different cultures and are able to provide culturally competent care.”

Today, in its expanded role, the cultural diversity office at the School of Nursing offers an Academic Enrichment Program in which a group of students meet about once a month for brown bag lunch discussions on a wide range of topics–from critical thinking skills and time management to working with culturally diverse patients. Lauderdale also coordinates a Pre-Nursing Society for freshmen and sophomores who are considering nursing as a career.

For faculty, the nursing school’s summer institute on teaching strategies includes discussions of how to celebrate cultural diversity in the classroom. In addition, Lauderdale works closely with the faculty member who directs the cultural diversity program in the School of Medicine.

Diversity Is a Full-Time Job

When Alexander came aboard at UNC, she turned what had previously been a part-time role into a full-time focus. “Prior to my [being hired], the issues relating to diversity and inclusion were part of an assignment [given to] someone else on the faculty,” she explains. For her predecessors, this function took up a relatively small percentage of their responsibilities.

“I came into the interview with a clear understanding, because of [my] past work experience in diversity, that if it wasn’t getting the full attention of someone and it was kind of the job of ‘everybody,’ it was not going to get the traction that it needed to get,” Alexander says.

Specific diversity enhancement strategies at her school include a continuing education requirement for faculty and staff that is linked to their performance evaluations and compensation; the Kindred Spirits Award for Excellence in Multicultural Scholarship, given each year at commencement to a student who exemplifies respect for diversity; and an Ethnic Minority Visiting Scholars Program.

All of these elements, Alexander says, make her days on the job “unpredictable and lots of fun.”

At Penn, Siantz works closely with the nursing school’s Master’s Curriculum Committee and Diversity Committee. She also partners with other groups within the school and throughout the campus that are interested in promoting diversity.

For example, Siantz has partnered with the university’s medical school to develop a Leadership Education and Policy Development program to promote leadership skills among nurses and physicians of color. Supported by the university vice provost’s Office for Diversity, this program also teaches them how to use their research and clinical practice to help shape public health policies to eliminate disparities.

Another key strategy for Siantz has been to become a faculty member of minority nursing student organizations on campus, holding leadership retreats with the groups’ outgoing and incoming boards.

Challenges and Rewards

All of the nursing school diversity directors interviewed for this article admit that the work they do has its share of challenges. Yet they also find it extremely rewarding, especially when they see that their efforts to promote diversity and inclusiveness are producing measurable results and making a real difference at their institutions.

Siantz says one of the biggest challenges in diversifying the nursing profession is that nursing schools need to extend their outreach beyond the college campus.

“We need to partner with the [elementary and secondary] school systems, because despite the fact that the numbers [of people of color] are growing, they’re not going to college,” she emphasizes. “That’s something that the schools in individual communities need to wrestle with in terms of how they’re going to change that picture over time.”

Stokes sums up the main barrier multicultural students face in advancing their nursing studies with one word: “Money.” For example, she says, “I’ve been in communication [recently] with a young lady who graduated from another university here in [Indianapolis]. She has attended several of [our] Connections programs, but right now it’s [the lack of] money that’s keeping her away [from pursuing doctoral studies here].”

On the plus side, the school has been successful in obtaining a National Institutes of Health grant that provides some scholarships and stipends for qualified nursing students. About 36 nursing students at Indiana have participated in the university-wide Summer Research Opportunities Program, and several have gone on to pursue graduate studies. “I think we have had more students in the program than any other unit [of the university],” Stokes comments.

Another success story for Stokes has been seeing the nursing school’s learning environment change for the better when it comes to faculty interaction with students from diverse backgrounds. “They just have a better understanding of students who are different from them,” she says.

At UNC, one of Alexander’s proudest accomplishments has been to have the School of Nursing become a national role model for promoting and achieving diversity.
“We are called on frequently to consult with other schools about how to walk the talk of inclusion,” she says.

Is This a Career for You?

Because nursing school diversity directors represent a newly emerging specialty, there is little data available about their current employment statistics, salary levels or the career outlook for the field. However, the U.S. Bureau of Labor Statistics reports that the mean annual wage for all education administrators in colleges, universities and professional schools was $86,480 in 2006.

What kind of background and experience would be prerequisites for this career? The BLS notes that top student affairs positions usually require an EdD or PhD, along with good interpersonal, leadership and decision-making skills.

The directors interviewed for this article all have credentials that fit that profile. Alexander has an MSN from Vanderbilt University, training as a family nurse practitioner and an EdD in educational administration and supervision from Tennessee State University. She also has work experience in both hospital and corporate settings. Just prior to arriving at UNC, she was the head of her own diversity consulting business in Nashville.

Lauderdale has an MSN with a major in maternal-child health from Texas Women’s University and a PhD in transcultural nursing from the University of Utah.

Stokes has an MSN from Indiana University School of Nursing and a PhD in instructional psychology with a minor in gerontology from Indiana University-Bloomington. She says her instructional psychology background, with its focus on teaching behaviors, is an asset in her current job.

Siantz has a master’s in child psychiatric nursing and community mental health from UCLA and a PhD in human development from the University of Maryland. Before accepting her position at the University of Pennsylvania, she was an associate dean and director of the Center for Excellence in Hispanic Health at Georgetown University.

Siantz believes the successful nursing school diversity director will be someone who is a visionary leader with excellent communication skills and strong relationship-building skills. “The person who is recruited to this position must be a senior-level person who not only walks the talk but also understands, and has a vision for, how to pull it forward,” she says.

Building Capacity: A Blueprint for Faculty Diversity

Most colleges and universities have strategic plans that articulate goals to strengthen faculty search procedures to increase the diversity of their staff. While such goals are important, they have come under attack in the past, even needing legal support. For example, Justice Sandra Day O’Conner in her Supreme Court majority opinion clearly communicated that the skills needed in today’s global market can only be developed by exposing students to “widely diverse people, cultures, ideas, and viewpoints.”1 The Association of American Universities has long communicated that diversity experiences not only enhance the education quality and outcomes of students from underrepresented populations, but of all students.2

The Sullivan Commission on Diversity in the Healthcare Workforce articulated that the health professions of the United States have not kept pace with changing demographics and may be more directly related to disparities in health access, status, and outcomes than the overall lack of health insurance. With minority populations projected to become the majority by 2050, health disparities may continue to worsen if health care professionals do not become more reflective of the populations they serve.3 The diversity challenge is even greater in the academic settings that educate undergraduate and graduate nurses. The American Association of Colleges of Nursing reported that less than 10% of faculty in baccalaureate and graduate nursing programs are from underrepresented groups, with 5.6% African Americans, 1.5% Hispanics, 1.9% Asian, and less than 1% American Indian/Alaskan Native documented.4

The lack of minority nurse educators communicates to students and communities of color that the profession does not value diversity. Lacking mentors and role models to support and enhance their education, students from underrepresented populations may not recognize the professional opportunities that exist for faculty in higher education, and the academic leadership that is needed from a diverse nursing workforce to eliminate health disparities in the 21st century.

The growing multicultural world that all student nurses enter requires exposure to a diverse faculty who bring varying research perspectives, pedagogy, and life experiences to the classroom, the laboratory, health systems, and the surrounding community. A critical need exists to create, implement, and evaluate blueprints for action that will attract, retain, support, and promote the leadership and success of faculty from underrepresented populations in schools of nursing. Action steps to be considered in blueprints should strive to:

    • Increase the applicant/pipeline pool of diverse faculty candidates from underrepresented populations
    • Promote a climate of diversity
    • Market for diversity
    • Prepare search committees to review diverse candidates
    • Retain diverse faculty

Increase the applicant pool

U.S. colleges and universities are educating a larger and more diverse group of students than ever before. According to the Educational Testing Service, student diversity will increasingly evolve over the next decade, with 80% of the anticipated 2.6 million new college students from underrepresented populations, including African Americans, Hispanics, Asian/Pacific Islanders, or American Indians. Undergraduate minority students enrolled in colleges and universities will increase from 29.4%–37.2%.5,6 Most recently, the report on the future of nursing acknowledged the need to respond to the under-representation of racial and ethnic minority groups, including men, in the nursing workforce.7

While a steady increase in the minority university student population has occurred, similar diversification among university faculty has not happened.8 Faculty diversification not only attracts diverse students, thus increasing the applicant pool and supporting academic program growth, but it also contributes directly to the quality of student education. Diverse faculty expose students to a wider range of scholarly perspectives and ideas that build on a variety of life experiences, create intellectual stimulation with new research questions, and foster fresh perspectives in the academic enterprise. Diversification is also the right action, not only from a social justice perspective, but based on business.9 The corporate world has long accepted a mandate that they must expand markets to serve diverse communities to survive in a competitive environment.

Action steps

    • A number of changes are needed to increase the applicant pool, such as developing partnerships with minority-serving institutions and establishing alumni directories of doctorally prepared minority graduates for consideration in post-doctoral or visiting scholar appointments. This action will promote scholarship and research of mutual interest to the scholar, the school, and the community.
    • Metrics should include memorandums of understanding with individual colleges or universities with results measured by the number of candidates identified from partnering institutions for recommendation to search committees. To assure the success of these partnerships with minority-serving institutions, ambassador programs could be developed by assigning faculty members to communicate and represent their respective schools of nursing at designated partner institutions.
    • Faculty who teach at these institutions could be invited to do a presentation and talk about promising students for post-doctoral consideration through a faculty exchange initiative. Schools of nursing must set aside resources to support minority scholars in residence as well. Finally, an academic faculty network should be considered so introductions can be made through the network to administrators from underrepresented populations at member institutions.

Promote a climate of diversity

While organizational climate has a range of definitions, Baird suggests common descriptors include friendliness, hostility, or acceptance.10 Organizational climate includes the current attitudes, behaviors, and standards/practices that concern the access to, inclusion of, and level of respect for individual and group needs, abilities, and potential. This definition includes all groups, not just those who have been traditionally excluded or underserved by colleges and universities.5

If a school of nursing is to succeed in terms of the retention and recruitment of faculty of color, it must embrace diversity. Turner and Myers report that faculty of color leave for many reasons, including hostile environments—a major factor discouraging potential applicants.6 In contrast, a school of nursing that provides an environment that supports the success of diverse faculty is attractive and facilitates recruitment and retention. Research has shown that endorsement from leaders provides credibility for such programs.11 It’s important that administrative support is reflected by publicly rewarding departments, divisions, and units who demonstrate measurable improvement. Support from the top and rewards for increasing diversity have been shown to be the two key factors that determine the success of diversity programs.12

Action Steps

    • Fostering assessment and accountability must begin with a faculty diversity climate survey and should include an exit survey for those that leave. Faculty surveys should include both quantitative and qualitative data that measures the diversity climate within the school of nursing. Results should be reported through school departments and discussed in faculty meetings with recommendations to the faculty at large, as well as search committees, specifically.
    • Activities that promote a supportive climate should be identified through departments and the faculty panel discussion. The PBS film Shattering the Silences: Minority Professors Break Into the Ivory Tower could be shown at department meetings, followed by faculty discussions led by a diversity expert. A panel discussion focused on faculty diversity should be a yearly faculty event. It is also recommended that faculty who have led and created activities that support a climate of diversity receive merit recognition from those administrators held accountable for achieving faculty diversity in their departments.
    • Resources should be established to conduct climate surveys and maintain an office of diversity to assure that planning, implementation, and evaluation occur. Ideally, a faculty leader who is also a member of the dean’s leadership team would coordinate these activities. This nurse faculty leader should provide a vision and structure for faculty initiatives that will not only support the inclusive climate needed for recruitment, retention, and promotion of diverse underrepresented faculty but that will involve the entire school in a program that sets achievable and measurable goals with a business plan.
    • As research is needed to investigate diversity, equity, and climate beyond race and ethnicity to include differentials in power and privilege, external research support through federal, foundational, and private grant mechanism should be explored. The diversity office should address the need to continue to support and develop academic programs that focus on issues of diversity, underserved populations, and societal disparities, which will attract diverse faculty and scholars. Pilot research on faculty climate could also be supported through these mechanisms; then a larger study could be launched with funds sought through the National Institute of General Medical Science, an NIH program.

Marketing for diversity

Communicating a school’s commitment to diversity, whether through conferences, national meetings, publications, posters, brochures, and/or official websites, ensures the transparency of the school’s diversity recruitment goals. Business research shows diversity marketing reduces turnover costs and inspires a desire to be part of a dynamic and responsive team. It also helps institutions win the competition for talent by attracting, retaining, and promoting faculty and leadership from underrepresented populations. Organizations cited as the best places for employment by diverse underrepresented groups also experience an increase in applications.13 Furthermore, research has shown endorsement from the organization’s leadership brings credibility to diversity programs and influences attitude change.11

Sullivan (2007) underlined the critical role academic leaders play in successful diversity programs. These leaders must create a culture within their academic units that supports the implementation of a strategic plan—one that establishes goals, defines success, and fosters accountability, best practices, and financial resources.14

Action steps

    • Schools of nursing can maintain a diversity website that links to the school’s departmental sites. This site must communicate that diversity in the organization is critical to the recruitment of faculty from underrepresented groups. It should also showcase the successes of faculty from underrepresented populations in research, teaching a diverse student body, collaborating with university faculty and diverse communities, and scholarly achievements.
    • An interactive school of nursing Facebook page reflecting the diversity of the school’s leadership team, faculty, and students is also needed for effective marketing. It should be updated on a regular basis and evaluated by the number of hits and links made by browsers. A member of the school’s leadership team should be designated to work with appropriate media resources to maintain and update an interactive website that showcases the school’s successful recruitment, retention, and promotion of diversity.

Strengthen the search committee’s success

Nationally, hundreds of campuses are engaged in competitive efforts to diversify their faculties in response to external and internal pressures. Yet, according to Caroline Sotello Viernes Turner, in her book Diversifying the Faculty: A Guidebook for Search Committees, five prevalent myths have hindered the hiring process of ethnically, racially, and gender underrepresented diverse faculty.15

  1. Good minority faculty only go to the best universities.
  2. To hire minorities, standards must be lowered.
  3. Minorities prefer the private sector.
  4. Espousing equal opportunity doctrine is sufficient.
  5. Minorities will not go to predominantly white institutions. 

Research published in the Journal of Higher Education in 2004 showed that among institutions with predominantly white populations, the hiring of faculty from underrepresented groups occurs when at least one of the following three conditions are met. First, the job description explicitly engages diversity at the department level. Second, an institutional “special hire” strategy is used, such as waiver of a search, target of opportunity hire, or spousal hire. Third, the search is conducted by an ethnically/racially diverse search committee.16 Search committees often approach their charge in a passive, routine way (i.e., advertise the position in publications, evaluate résumés, invite three to five candidates for campus interviews, and then make an offer).

To address the need to recruit faculty from underrepresented racial/ethnic or gender diverse populations in a school of nursing, the search committee must take a more proactive approach to finding candidates from such populations. All steps taken during the search process can contribute to a solid foundation for the successful retention of diverse faculty hired as well as ongoing successful recruitment into the future.

Viernes Turner writes that schools of nursing should focus on eight action steps to form successful hiring committees:15

  1. Diversify the search committee itself.
  2. Educate the search committee on personnel issues and prepare the members through an annual retreat.
  3. Debunk the myths listed above.
  4. Create tailored position descriptions.
  5. Attract diverse candidate pools.
  6. Examine hiring biases.
  7. Host campus visits
  8. Make the offer.

The campus visit is also a critical moment of opportunity that allows the candidate to make a well-informed decision on whether the position and the school of nursing is a right fit. Evaluation forms should be provided to all campus parties involved in the visit and discussed by the committee. Asking the candidate to comment on the process will also provide the school’s search committee with information to improve the process for subsequent campus visits. It is important to not only evaluate the candidate, but also the search committee process, in order to improve the chances of reaching the desired outcome.

Action Steps

    • First, assuring that the composition of the search committee has different points of view is critical to its success. Members who represent diverse populations must be appointed.
    • Next, preparing the committee through a yearly retreat that addresses unconscious hiring bias and debunking of myths must be used in conjunction with current university guidelines to prepare new members and refresh returning members for the year’s goals. An annual search committee evaluation plan should be implemented to review the effectiveness of the diversity recruitment process. Metrics should include a percentage increase of the diversity applications and a percentage increase in hires.
    • Departments then need to conduct their own hiring patterns audit, examining the tenure track and associated clinical and research faculty patterns. At the annual evaluation discussion of department recruitment needs, a diversity recruitment plan must be developed and sent to the search committee prior at the beginning of the academic year.
    • Finally, a departmental diversity awards program will need to be established to acknowledge excellence in diversity recruitment and support of a climate of diversity that recruits and retains racially/ethnically and gender diverse faculty.

Retain a diverse faculty

The most successful universities have both a strong commitment and action plans that support faculty diversity.17 An important and overlooked strategy to retain professors from underrepresented populations is to create a critical mass to prevent feelings of isolation and alienation that result in leaving.15

Action steps

    • Mentorship programs should be established that help guide diverse faculty through promotions and tenure tracks. These programs should be advertised on school of nursing websites and shared with potential candidates. Diverse faculty should also be mentored in their achievement of awards that recognize excellence in research and teaching. Finally, ongoing mentorship will be needed to develop the leadership potential of diverse faculty, with recognition given for such leadership.
    • Resources must be designated to support family policies as needed by candidates; these should be marketed through the search committee process and the website. Funds will be needed for startup packages that will support pilot work and presentations of scientific findings at national or international meetings. Support may be needed for the development of untenured new faculty hires as well. Finally, exit interviews should be considered for tenured and untenured diverse faculty at departure to explore reasons for leaving the university.

Using a blueprint to transform an institution to reflect a pluralistic society requires the collective evaluation of attitudes, the behaviors they generate, and the unconscious bias that shape faculty actions.18 Critical to this process is a vigilant and widespread diversity campaign that promotes individual ownership of the blueprint for change and is advocated and supported by both the faculty and school leadership.

A need exists for schools of nursing to showcase a vision and strategy for recruitment, retention, and promotion of a faculty that reflects the diversity of the United States and the world whose health they plan to promote. And as Benjamin Franklin once said, “By failing to prepare, you are preparing to fail.”


  1. Barbara Grutter v. Lee Bollinger, et al. 124 U.S. 35 (2003).
  2. Association of American Universities (1997, April 24). “On the Importance of Diversity in University Admissions.” The New York Times, p. 27.
  3. Sullivan, Louis W. (2004). Missing Persons: Minorities in the Health Professions, A Report of the Sullivan Commission on Diversity in the Health Care Workforce. Sullivan Commission, p. 66
  4. Berlin, L., E., Stennett, J., and Bednash, G.D. (2004). 2003–2004 Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing. American Association of Colleges of Nursing.
  5. Rankin, S. & Reason, R. (2008). “Transformational Tapestry Model: A comprehensive approach to transforming campus climate,” Journal of Diversity in Higher Education, 1:4, 262–274.
  6. Turner, C., S.V. & Myers, S.L. (2000). Faculty of Color in Academe: Bittersweet Success.
  7. Institute of Medicine (2010). The Future of Nursing: Leading Change, Advancing Health.
  8. Sullivan, C.W., & Bristow, L.R. (2007). “Summary Proceedings of the National Leadership Symposium on Increasing Diversity in the Health Professions.” Sullivan Alliance, 1–12.
  9. Correll, S. J. & Benard, S. (2006). “Biased Estimators? Comparing Status and Statistical Theories of Gender Discrimination.Social Psychology of the Workplace (Advances in Group Processes, Shane R. Thye and Edward J. Lawler eds.) Vol. 23, 89–116.
  10. Baird, L. L. (2005) College Environments and Climates: Assessments and Their Theoretical Assumptions. In J.C. Smart (ed.), Higher Education: Handbook of Theory and Research, Vol. 20, 507–538.
  11. Fiske, S. & Taylor, S.E. (1999). Social Cognition, 2nd edition.
  12. Rynes, S. & Rosen, B. (1995). “A Field Survey of Factors Affecting Adopting and Perceived Success of Diversity Training.” Personnel Psychology, Vol. 48, 247–270.
  13. Robinson, G., & Dechant, K. (2007). “Building a Business Case for Diversity.” Academy of Management Perspectives, 11:3, 21–31.
  14. Siantz, de Leon, M.L (May – June 2008). “Leading Change in Diversity and Cultural Competence.” Journal of Professional Nursing, 24:3, 167–171.
  15. Viernes Turner, C.S. (2002). Diversifying the Faculty: A Guidebook for Search Committees, Association of American Colleges and Universities.
  16. Smith , D.G., Turner, C.S., Osei-Kofi, N., Richards, S. (2004). “Interrupting the Usual: Successful Strategies for Hiring Diverse Faculty. The Journal of Higher Education, 75:2, 133–160.
  17. Piercy, F.; Giddings, V.; Allen, K.; Dixon, B.; Meszaros, P.; & Joest, K. (2005). “Improving Campus Climate to Support Faculty Diversity and Retention: A Pilot Program for New Faculty.” Innovative Higher Education, 30:1, 53–66.
  18. Handelsman, et al. (2005). “More Women in Science.” Science, 309:5738, 1190–1191.

Learning About Difference

Ask a student entering nursing school why nurses need to use different criteria in diagnosing cyanosis in African Americans, why a Vietnamese mother might leap up in terror when a nurse touches her child’s head or why some Asians are fearful of health care providers in white uniforms. Chances are, the student will not have a clue.

But after spending a year at one of the growing number of nursing schools that offer multicultural education, they will know the answers to those questions and many more. They will have learned that African Americans’ skin turns dusky, not blue, when they’re cyanotic; that some Vietnamese mothers believe evil spirits will visit their child if strangers touch the head; and that certain Asian cultures associate white with death.

As people of diverse races, ethnicities and cultures continue to cover the U.S. like a colorful quilt, nursing schools are recognizing the importance of teaching students about diversity before they enter the workplace, where they will face patient care situations that demand cultural and linguistic sensitivity.

In health care, cultural competency means treating patients from different racial and ethnic backgrounds, as well as the elderly and indigent, in accordance with their unique cultural needs, beliefs and risk factors. Linguistic competency means being able to converse in a limited-English-speaking patient’s native tongue or having access to a qualified translator.

Cultural and linguistic competency benefits the entire health care system because it is a more holistic approach to health, educators say. And it’s desperately needed as the nation’s minority population continues to increase in the face of health risks that disproportionately affect those populations, according to Kem Louie, RN, PhD, president of the Asian American/Pacific Islander Nurses Association and associate professor in the Department of Nursing at William Paterson University in Wayne, N.J. “The devastating statistics concerning the health disparities among ethnic minority groups in America rival those of Third World countries,” she says.

Although the U.S. Office of Minority Health recently issued first-ever national standards for culturally and linguistically appropriate services (CLAS) for health care organizations and providers, no such federal guidelines exist for incorporating cultural and linguistic competency into nursing school curricula. Nevertheless, nursing schools around the country are rising to the challenge on their own and designing multicultural programs of study.

A Diversity of Approaches

Colleges of nursing vary in how they have chosen to incorporate cultural and linguistic competency into their curricula. Some schools have gone so far as to throw out their existing curricula and start afresh. Others have created separate teaching units focused exclusively on cultural competency. Still others are weaving cultural competency education throughout their traditional curricula. In addition, some schools recommend or even require students to take cultural anthropology courses and to study a second language in order to increase their cultural and linguistic competency.

This educational refocusing reflects both America’s growing cultural diversity and the expanding role of nurses at the dawn of the new millennium. Not only are today’s nurses expected to provide health care, they are also being called on to act as liaisons between the health care system and the patient. Shirlee Drayton-Hargrove, RN, PhD, co-editor/author of the book Case Studies in Multiculturalism, calls this being a cultural broker.

“[Nurses] need to have extensive knowledge of, and respect for, differences in cultures when dealing with patients,” says Drayton-Hargrove, who is director of the Family Nurse Practitioner program and an assistant professor at Widener University in Chester, Pa. “They must have awareness of subcultures—such as knowing that Latinos don’t all speak the same language and that African Americans don’t all like the same kind of foods. They also need to know what to do when cultural differences become obstacles in caring for patients.”

Widener’s undergraduate school of nursing teaches multicultural concepts by integrating them throughout the curriculum and offering students opportunities to gain practical experience working with diverse patients at local clinics. For the past eight years, the school has also assembled ethnically diverse panels to discuss cultural competency with students. The format has been highly successful, says Jane Brennan, RN, DNSc, assistant dean for undergraduate studies.

The university’s graduate nursing program takes the same approach, often calling upon its diverse student population to offer insights into their own cultures. “It’s like a little United Nations here,” says Mary Walker, RN, EdD, dean of graduate nursing. “We have students from everywhere, including a growing number from the Middle East. We sponsor International Days, where students present projects on a particular culture and its beliefs. We even have a writing center and language institute on campus to help students learn the languages of the populations they are working with.”


At the University of Utah in Salt Lake City, students in the undergraduate nursing program learn about different cultures not only in the classroom but also by working at shelters, clinics and the university’s hospital. “They come back to class wide-eyed and with a wealth of new knowledge,” reports Sue Chase-Cantarini, RN, MS, clinical instructor and coordinator of diversity affairs at the university.

They learn, for example, that Hispanics—who comprise a high percentage of the minority population in Salt Lake City—tend to consult with family members before making major medical decisions; that people from certain cultures may assume doctors and nurses know what’s wrong with them without having to ask questions; and that some Native Americans can be traumatized if a health care provider tries to remove the little bags containing essential oils that are often worn around the neck for healing. Other cultures wear jewelry they believe has healing properties, and students learn that they can tape over the jewelry prior to surgery, rather than cut it off.

To reinforce this cultural learning, instructors at the University of Utah hold “debriefing sessions” at the community clinics and other setting where the students have been working. In addition, the nursing school holds monthly seminars, sponsored by the university’s Office of Minority Affairs, in which health care workers from different ethnic groups lead classroom discussions on the challenges of providing health care to particular minority cultures.

The Community as Classroom

Perhaps the most dramatic and innovative example of teaching cultural competency in nursing school can be found at the University of Central Florida in Orlando. In 1997, the university’s nursing program scrapped its traditional undergraduate curriculum and replaced it with one centered almost entirely on clinical experience in the community.

“We’re breaking down the walls,” says Ermalynn Kiehl, ARNP, PhD, who coordinates the flow of nursing students into community clinics. “Not many schools are making such drastic changes.”

Students spend the entirety of their first semester at senior centers, schools and clinics, doing health screenings and assessing the needs of the local population, which is 40% minority—primarily African American, Hispanic and Haitian. Second-semester students spend half of their time working in the community and the other half coordinating the long-term care of patients they worked with in their first semester.

To maintain continuity of care, clinical work in the community is also emphasized in the student’s third semester. “You can’t jump in and out of the community just to satisfy the needs of the curriculum,” Kiehl explains. “It’s not fair to the people being served.”

“Our students love the new curriculum,” says Elizabeth Stullenbarger, RN, DSN, director of nursing and professor at the university. “Many of them come from the same ethnic backgrounds as their patients, so they speak the same language.” In cases where language barriers are a problem, she adds, the students are so diverse that they can translate for each other.

When they first start working in the community, Stullenbarger continues, students sometimes feel they aren’t learning traditional nursing skills. “But they soon realize that they are learning the basics. They learn how to do blood pressure checks and give injections, as well as how to perform other procedures.” Most important of all, they are learning how to provide culturally competent health care to a wide variety of patients.

Creating Culturally Aware Nurses

At South Carolina State University (SCSU) in Orangeburg, S.C., cultural competency training is a strong component of classroom instruction, says Ruth Johnson, RN, EdD, FAAN, professor and chair of the Department of Nursing. Because most of the students at South Carolina State are African American, she says, the topic of culture “is a given.” Even before the expression “cultural competency” came into being, nursing students at SCSU were learning to communicate with patients who speak Gullah, a Creole language now spoken primarily in nearby Charleston by descendants of African slaves.

Although still predominantly African American, SCSU has recently begun to attract students from Africa, Iran, Afghanistan and other countries. Orangeburg itself has seen an influx of Japanese, Koreans and Central and South Americans, which has made it even more crucial for students to learn about different cultures, Johnson notes.

Up north in Chicago, always a melting pot for different races and ethnicities, adding a multicultural component to courses in nursing at the University of Illinois at Chicago was the obvious thing to do, says Eva D. Smith, RN, PhD, associate professor in the university’s College of Nursing, where students from around the world learn about a variety of cultures in seminars, workshops and independent study programs.

Cultural competency, Smith stresses, must begin with an understanding that “culture” is defined not only in racial and ethnic terms, but also by religious, socioeconomic and geographic differences. As part of their multicultural training, nursing students at the University of Illinois choose someone from a different cultural background than their own—perhaps a fellow student or next door neighbor—and follow that person through the semester. They study what the person eats, his or her health practices and the habits dictated by the subject’s culture. This in-depth approach, Smith says, helps students appreciate and value cultural differences.

While educators say that most nursing students are eager to share their own cultures with their classmates, Cantarini-Chase has found that some students worry about being treated as token minorities and resent being called on to answer questions pertaining to their ethnic group. “They take it as an insult,” she cautions, “so we need to be careful.” Still other students may reject the whole differentiated-culture approach, demanding “Can’t you just call us all human beings?”

But overall, such views seem to be the exception, not the rule. “Students are very accepting of cultural competency here,” Smith says of University of Illinois nursing students. “At the end of each semester, we hold a potluck luncheon and students and faculty bring their favorite ethnic dish. Forty percent of our students are Asian, African American or Hispanic, with a smattering of Russian and Yugoslavian students. We talk about cultural pluralism and each student brings something valuable to the discussion.

“When we first ask students how they identify themselves,” she adds, “most say, ‘I’m American.’ But four years later, they say, ‘I’m Asian,’ or ‘I’m Mexican,’ or whatever their culture is. Students need to come to terms with their own cultural identities before they can really understand and appreciate other cultures.”

Johnson notes that some students may initially be nervous about working with people who are culturally different from them, whether the difference involves race, nationality, generation or socio-economic status. “But we quickly start seeing that the students are responding favorably to their exposure to other cultures,” she says. “Some have said, ‘Before this, I would never have taken time to talk with elderly people.’”

Faculty Involvement is Key

Nursing schools agree that cultural competency programs work best when the faculty acknowledge and support the need for such an approach—something that can take a bit of persuasion. “Faculty members have a difficult time giving up educational content they know well and are comfortable with,” Kem Louie says.

One way to foster faculty enthusiasm and cooperation is to involve them in formulating the new curriculum. At SCSU, the predominantly African-American faculty “owned the cultural competency curriculum,” Johnson says. “They helped design the program, using their own experiences—personal and professional.”

The same is true at Widener University, Walker relates. “It’s a work in progress. For example, if faculty members want to update the curriculum to reflect new research or emerging trends, they can. There isn’t a lot of red tape.”

Like most American colleges and universities, Widener does not have many minority faculty members. While the University of Illinois’ Smith believes “you don’t need to be a minority to teach cultural competency,” all of the educators interviewed for this article say they would welcome a more racially and ethnically diverse faculty.

Louie feels it’s crucial that both Caucasian and minority faculty members work together to develop their school’s cultural competency program. “In my experience,” she says, “it has been the minority faculty who have predominated in introducing cultural and linguistic competency into the curricula. We need to send the message that majority groups must also be active in addressing cultural competency.”